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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600546
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:05:26 PM

Document Has Been Signed on 11/01/2023 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:CAL-CRIS LODGEFACILITY NUMBER:
374600546
ADMINISTRATOR:GLADYS BELTRANFACILITY TYPE:
735
ADDRESS:8944 EMERALD GROVE AVENUETELEPHONE:
(619) 390-8501
CITY:LAKESIDESTATE: CAZIP CODE:
92040
CAPACITY: 10CENSUS: 10DATE:
11/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:caregiver, Julita RenojoTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Rodgers and Licensing Program Manager (LPM) Denise Powell conducted a Case Management visit to address deficiencies. The facility file was reviewed prior to the visit. LPA and LPM were greeted and allowed entry into the facility by caregiver, Julita Renojo, to whom LPA and LPM discussed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of ten (10) ambulatory clients. During today’s inspection, there were ten(10) clients in care.



LPA and LPM, accompanied by caregiver Renojo, toured the interior and exterior of the facility, and inspected each room along with bathrooms. The facility was clean and in adequate repair. There were at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. LPA and LPM reviewed a sampling of client records and required documents were present.

Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with Caregiver Ronojo. LPA provided technical guidance.

An exit interview was conducted with Caregiver Renojo, to whom copies of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/01/2023 03:05 PM - It Cannot Be Edited


Created By: Amy Rodgers On 11/01/2023 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CAL-CRIS LODGE
FACILITY NUMBER: 374600546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2023
Section Cited
CCR
850088(b)(3)

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85088 Fixtures, Furniture, Equipment and Supplies(a) In addition to Section 80088, as a condition of licensure, the following shall apply.(3) Toilets and bathrooms shall be located near client bedrooms.
This requirement was not met as evidenced by:
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Staff agreed to keep bathroom door unlocked at all times for client access. During visit was unlocked and lock sign was removed. Staff agrees that the key lock will be removed and replaced with a punch lock.
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Observations showed bathroom near client bedrooms was locked and not accessible. This posed a potential personal rights risk to 6 of 10 clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Denise Powell
LICENSING EVALUATOR NAME:Amy Rodgers
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
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